Surgery for open frontobasal fractures

Introduction: Patients with frontobasal fractures and a persisting CSF leak have to undergo surgery. The question is by which methods and at what time a successful closure of the CSF leak can be achieved without further damage to the brain and least risk for the patient. Methods: Between 1990 and 1996 43 patients with frontobasal fractures and a persisting CSF leak were operated upon in our department. Whenever possible, surgery was performed between the 10th and 20th day post trauma, after CT showed a resolution of the initial brain edema. A bifrontal craniotomy was performed in all patients. The paranasal sinuses where treated in close cooperation with the ENT and the maxillo-facial surgeon, when fractures were present in these areas. Intradural inspection was performed and the CSF fistula closed with a periostal flap or a free muscle flap. Results: Four of the 43 patients had to be operated upon immediately because of an epidural hematoma or severe depressed fractures. 39 patients were operated upon between the 10th and 20th after the trauma. Successful closure of the CSF leak was achieved by the first procedure in 39 patients, 2 patients had to be operated upon again because of a persisting CSF leak, and 2 underwent an additional transnasal operation because the CSF fistula was caused by fractures extending into the temporal fossa. In 2 patients we saw frontal contusions after surgery, both patients recovered completely 4 to 8 weeks after surgery. Discussion: This series shows that patients with frontobasal fractures and CSF fistula can safely and successfully be operated on by means of a bifrontal craniotomy and intradural inspection. Surgery should be performed in cooperation with the ENT and the maxillo-facial surgeon. If possible, surgery should be postponed to the period between the 10th and the 20th day post trauma in order to prevent additional trauma to the brain.